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2004-229J
Indian River County Grant Contract This Grant Contract ("Contract" ) entered into effective this 1 st day of October 2004 by and between Indian River County, a political subdivision of the State of Florida , 1840 25th Street , Vero 32960 ("County") and Center for Emotional & Behavioral Health ( Recipient) , of: Wenterli MI- 190 37th Street i Vero Beach , Florida 32960 Background Recitals A. The County has determined that it is in the public interest to promote healthy children in a healthy community. B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance") and established the Children 's Services Advisory Committee to promote healthy children in a healthy community and to provide a unified system of planning and delivery within which children 's needs can be identified , targeted , evaluated and addressed . C . The Children 's Services Advisory Committee has issued a request for proposals from individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling its purpose . D . The proposals submitted to the Children 's Services Advisory Committee and the recommendation of the Children 's Services Advisory Committee have been reviewed by the County. E . The Recipient , by submitting a proposal to the Children 's Services Advisory Committee , has applied for a grant of money ("Grant") for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (as such term is hereinafter defined ) on the terms and conditions set forth herein . NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged , the parties agree as follows : 1 . Background Recitals The background recitals are true and correct and form a material part of this Contract. 2 . Purpose of Grant The Grant shall be used only for the purposes set forth in the complete proposal submitted by the Recipient attached hereto as Exhibit "A" and incorporated herein by this reference (such purposes hereinafter referenced as "Grant Purposes") . 3 . Term The Recipient acknowledges and agrees that the Grant is limited to the fiscal year 2004/2005 ("Grant Period ") . The Grant Period commences on October 1 , 2004 and ends on September 30 , 2005 . - 1 - 4 . Grant Funds and Payment The approved Grant for the Grant Period is Fifty Thousand Dollars ($50 , 000 ) . The County agrees to reimburse the Recipient from such Grant funds for actual documented costs incurred for Grant Purposes provided in accordance with this Contract. Reimbursement requests may be made no more frequently than monthly. Each reimbursement request shall contain the information , at a minimum , that is set forth in Exhibit "B" attached hereto and incorporated herein by this reference . All reimbursement requests are subject to audit by the County. In addition , the County may require additional documentation of expenditures , as it deems appropriate . 5 . Additional Obligations of Recipient . 5 . 1 Records . The Recipient shall maintain adequate internal controls in order to safeguard the Grant. In addition , the Recipient shall maintain adequate records fully to document the use of the Grant funds for at least three (3 ) years after the expiration of the Grant Period , The County shall have access to all books , records , and documents as required in this Section for the purpose of inspection or audit during normal business hours at the County's expense , upon five (5) days prior written notice . 5 .2 Compliance with Laws . The Recipient shall comply at all times with all applicable federal , state , and local laws , rules , and regulations . 5 . 3 Quarterly Performance Reports , The Recipient shall submit Quarterly Performance Reports to the Human Services Department of the County within fifteen ( 15 ) business days following : December 31 , March 31 , June 30 , and September 30 . 5 .4 Audit Requirements . If Recipient receives $25 , 000 or more in the aggregate from all Indian River County government funding sources , the Recipient is required to have an audit completed by an independent certified public accountant at the end of the Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the Recipient shall submit the audit to the Indian River County Office of Management and Budget. The fiscal year will be as reported on the application for funding , and the Recipient agrees to notify the County prior to any change in the fiscal period of Recipient . The Recipient acknowledges that the County may deny funding to any Recipient if an audit required by this Contract for a prior fiscal year is past due and has not been submitted by May 1 . 5 .4 . 1 The Recipient further acknowledges that , promptly upon receipt of a qualified opinion from it's independent auditor, such qualified opinion shall immediately be provided to the Indian River County Office of Management and Budget . The qualified opinion shall thereupon be reported to the Board of Commissioners and funding under this Contract will cease immediately. The foregoing termination right is in addition to any other right of the County to terminate this Contract. 5 . 4 . 2 The Indian River County Office of Management and Budget reserves the right at any time to send a letter to the Recipient requesting clarification if there are any questions regarding a part of the financial statements , audit comments , or notes . 5 . 5 Insurance Requirements . Recipient shall , no later than September 21 , 20041 provide to the Indian River County Risk Management Division a certificate or certificates issued by an insurer or insurers authorized to conduct business in Florida that is rated not less than category A- : VII by A. M . Best, subject to approval by Indian River County's risk manager, of the following types and amounts of insurance : - 2 - ( i ) Commercial General Liability Insurance in an amount not less than $ 1 , 000 , 000 combined single limit for bodily injury and property damage , including coverage for premises/operations , products/completed operations , contractual liability, and independent contractors ; (ii ) Business Auto Liability Insurance in an amount not less than $ 1 , 000 , 000 per occurrence combined single limit for bodily injury and property damage , including coverage for owned autos and other vehicles , hired autos and other vehicles , non -owned autos and other vehicles ; and (iii ) Workers ' Compensation and Employer's Liability (current Florida statutory limit) 5 . 6 Insurance Administration . The insurance certificates , evidencing all required insurance coverages shall be fully acceptable to County in both form and content , and shall provide and specify that the related insurance coverage shall not be cancelled without at least thirty (30 ) calendar days prior written notice having been given to the County. In addition , the County may request such other proofs and assurances as it may reasonably require that the insurance is and at all times remains in full force and effect. Recipient agrees that it is the Recipient's sole responsibility to coordinate activities among itself, the County, and the Recipient's insurer(s ) so that the insurance certificates are acceptable to and accepted by County within the time limits set forth in this Contract . The County shall be listed as an additional insured on all insurance coverage required by this Contract, except Workers ' Compensation insurance . The Recipient shall , upon ten ( 10 ) days' prior written request from the County, deliver copies to the County, or make copies available for the County's inspection at Recipient's place of business , of any and all insurance policies that are required in this Contract . If the Recipient fails to deliver or make copies of the policies available to the County; fails to obtain replacement insurance or have previous insurance policies reinstated or renewed upon termination or cancellation of existing required coverages ; or fails in any other regard to obtain coverages sufficient to meet the terms and conditions of this Contract, then the County may, at its sole option , terminate this Contract . 5 . 7 Indemnification . The Recipient shall indemnify and save harmless the County, its agents , officials , and employees from and against any and all claims , liabilities , losses , damage , or causes of action which may arise from any misconduct , negligent act, or omissions of the Recipient, its agents , officers , or employees in connection with the performance of this Contract. 5 . 8 Public Records . The Recipient agrees to comply with the provisions of Chapter 119 , Florida Statutes ( Public Records Law) in connection with this Contract . 6 , Termination , This Contract may be terminated by either party, without cause , upon thirty (30 ) days prior written notice to the other party. In addition , the County may terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the Recipient if the County determines that such termination is in the public interest. 7 . Availability of Funds . The obligations of the County under this Contract are subject to the availability of funds lawfully appropriated for its purpose by the Board of County Commissioners of Indian River County. 8 . Standard Terms , This Contract is subject to the standard terms attached hereto as Exhibit C and incorporated herein in its entirety by this reference . - 3 - r IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date first above written . INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS Ogg Caroline D . Ginn , Chair mz ani ,;, BCC Approved : I Attest : J K : Clerk at .� By. DepLtya Olefk Approved : C Jose h A . Baird County Administrator A d t rm and legal su i nc arn . Fell , As istant QbiaRt 'Atfoirney RECIPIENT : By. Ce r Emtional & Behavioral Health 4 - EXHIBIT A [Copy of complete proposal/application] - 1 - The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC PROGRAM COVER PAGE Organization Name : The Center for Emotional and Behavioral Health @ IR 4H Executive Director : Dr. Raymond Dean MD &mail : rUmond . dean@irmh . org Address : 1190 37th Street Telephone : 772- 563 -4666 ext 1809 Vero Beach, FL 32960 Fax: 772-770-2025 Program Director : Mariamma Pyngolil RN E-mail : mariamma. pyngoliL1@irmh . org org Address : 1190 370' Street Telephone : 772-563 -4666 ext 1838 Vero Beach, FL 32960 Fax : 772-770-2025 Program Title : Group Therapy Program for Children and Adolescents Priority Need Area Addressed. Therapeutic, intervention and educational group therapy program for children and adolescents with emotional problems and/or behavior problems in Indian River Count Brief Description of the Program : RP450. 050 Adolescent/Youth Counseling : Programs that specialize in the treatment of adolescents usually age twelve or thirteen to seventeen who have adjustment problems behavior problems emotional disturbances a personality disorder or incipient mental illness . RP450. 155 Child Guidance : Programs that specialize in the treatment of children until age twelve who have adjustment problems, behavior problems, emotional disturbances, a personality disorder or incipient mental illness RP450 675 Psychiatric Disorder Counseling_ Programs that specialize in the treatment of individuals who have identified mental or emotional disorders with the objective of helping them to eliminate or reduce the severity of their symptoms to mediate disturbed patterns of behavior, to promote positive personality growth and development and to maximize the individual ' s ability to function as independently as possible Treatment may utilize therapeutic techniques derived from one or more theoretical counseling approaches SUMMARY REPORT — (Enter Information In The Black Cells Only) Amount Requested from Funder for 2004 /05 : $ 51 , 005 . 07 Total Proposed Program Budget for 2004 /05 : $ 88 , 549 . 45 Percent of Total Program Budget : 57 . 6 % Current Program Funding ( 2003 /04 ) : $ _ Dollar increase/ ( decrease ) in request : $ 51 , 005 Percent increase /( decrease ) in request * * : # DIV /0 ! Unduplicated Number of Children to be served Individually : 270 Unduplicated Number of Adults to be served Individually : _ Unduplicated Number to be served via Group settings : 55 Total . Program Cost per Client : 272 . 46 * * If request increased 5 % or more, briefly explain why : 3 + A 01 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and adolescents — IRC- CSAC If these funds are being used to match another source, name the source and the $ amount : The Organization 's Board of Directors = approve this application date Charles V . Shechayi Name of V4esi4ei/Chair of the Board Signatu e SU51KI Name of Executive Director/CEO 4 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC PROPOSAL NARRATIVE Please respond to each question in the allotted space for each section. In responding to each section of the proposal narrative, please retain the section-label and/or question that you are addressing. Type using 12 pt. font on 8 %" X l l " paper and number each page. These directions and the graphic boxes may be deleted if space is needed . A. ORGANIZATION CAPABILITY (Entire Section A not to exceed one page) 1 . Provide the mission statement and vision of your organization. Indian River Memorial Hospital strives to be the finest community based health care organization anywhere. Our values are compassion, respect, and teamwork. The Center for Emotional and Behavioral Health P, IRMH is committed to provide excellence in Mental Health Care to the individual and families while responding to the needs of the changing community. Our patients can expect quality care with dignity and professionalism through the collaborative efforts of the multidisciplinary team . We will continue to support the Quality First process while working together as a team . Group Therapy Program is committed to improving the lives of children and adolescents who are challenged by psychiatric disorders and/or behavioral problems . 2 . Provide a brief summary of your organization including areas of expertise, accomplishments, and population served. CEBH provides Mental Health services to children, adolescents and adults . Psychiatric clinicians are located in the Emergency Department of IRMH and provide a comprehensive psychiatric assessment to determine level of care for the community. In patient services are provided on a voluntary or involuntary basis to all three age groups . The facility also provides out-patient therapy for children/adolescents and their families , parenting classes, EAP services, urine drug screens/drug free workplace services, a summer camp (Camp Manatee Therapeutic Summer Camp) for ADHD children and Experiential (ROPES teambuilding) services to the community Group Therapy Program a treatment modality for Children and Adolescents who present with . psychiatric disorders and/or behavioral problems . Two therapists, one of whom must be licensed , who have expertise working with this population will co-facilitate these groups . These Group Therapy Programs will be coordinated by a licensed clinical psychologist . 5 r •� ,; The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC B. PROGRAM NEED STATEMENT (Entire Section B not to exceed one page) 1 . a) What is the unacceptable condition requiring change? b) Who has the need? c) Where do they live? d) Provide local, state, or national trend data, with reference source, that corroborates that this is an area of need. Children diagnosed with psychiatric disorders and/or behavioral problems do not always respond to individual psychotherapy. The research in this area shows that group therapy, when used in conjunction with individual therapy, is helpful in reducing the length of therapy and promotes positive change and healing. Despite this finding, insurance companies do not pay for group therapy. As an unfortunate result, many providers do not offer this powerful intervention strategy. http ://www .drbaltematives . com/articles/gcl .html Adapted from S .U .N . Y. at Buffalo What is Group Therapy? In group therapy approximately 6- 10 individuals meet face-to- face with a trained group therapist. During the group meeting time, members decide what they want to talk about. Members are encouraged to give feedback to others . Feedback includes expressing your own feelings about what someone says or does . Interaction between group members are highly encouraged and provides each person with an opportunity to try out new ways of behaving; it also provides members with an opportunity for learning more about the way they interact with others . It is a safe environment in which members work to establish a level of trust that allows them to talk personally and honestly. Group members make a commitment to the group and are instructed that the content of the group sessions are confidential . It is not appropriate for group members to disclose events of the group to an outside person. Why is group therapy helpful? 1 . When people come into a group and interact freely with other group members, they usually recreate those difficulties that brought them to group therapy in the first place. Under the direction of the group therapist, the group is able to give support, offer alternatives, and comfort members in such a way that these difficulties become resolved and alternative behaviors are learned. 2 . The group also allows a person to develop new ways of relating to people. 3 . During group therapy, people begin to see that they are not alone and that there is hope and help . It is comforting to hear that other people have a similar difficulty, or have already worked through a problem that deeply disturbs another group member. 4 . Another reason for the success of group therapy is that people feel free to care about each other because of the climate of trust in a group. As the group members begin to feel more comfortable, you will be able to speak freely. The psychological safety of the group will allow the expression of those feelings which are often difficult to express outside of group . You will begin to ask for the support you need . You will be encouraged tell people what you expect of them. In a group, you probably will be most helped and satisfied if you talk about your feelings . It is important to keep . in mind that you are the one who determines how much you disclose in a group . You will not be forced to tell you deepest and innermost thoughts . 2 . a) Identify similar programs that are currently serving the needs of your targeted population ; b) Explain how these existing programs are under-serving the targeted population of your program. Unaware of any other weekly Group Therapy Program for adolescents and children with psychiatric disorders . 6 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC Co PROGRAM DESCRIPTION (Entire Section C, I — 6, not to exceed two pages) 1 . List Priority Needs area addressed. Therapeutic, intervention and educational group therapy program for children and adolescents with emotional problems and/or behavior problems in Indian River County 2 . Briefly describe program activities including location of services . The material for these Group Therapy Programs are different for children and adolescent groups as each group addresses age specific issues as well as age specific skill development. The Children ' s group ages are 542 and Adolescent ' s group are ages 13 - 17 . Both Group Therapy Programs will meet at Center for Emotional and Behavioral Health. An example of the Group Therapy Programs are as follows : Monday Tuesday Wednesday Thursday Friday 3 -4 pm Self- Anger Sexual Abuse Divorce Group Family Adolescent ' s mutilation Management Group Issues Group Group Group Group 4-5 pm Self- Coping Skills Anger Understanding Loss Children ' s esteem Group Management Feelings Group Group Group Skills Group Group 1 . Each group is limited to one hour. 2 . Each group is limited to 12 pateitns. 3 . Once each 18 week session begins, no one new will be allowed to join, due to confidentiality. 4. Each group will be facilitated by two therapists ; at least one therapist shall be licensed. 3 . Briefly describe how your program addresses the stated need/problem. Describe how your program follows a recognized "best practice" (see definition on page 12 of the Instructions) and provide evidence that indicates proposed strategies are effective with target population. The therapeutic experience of the group process is divided into eleven primary factors that address best practice. These eleven primary factors are installation of hope, universality, imparting information, altruism, the correct recapitulation of the primary family group, development of socializing techniques , imitative behavior, interpersonal learning, group cohesiveness, catharsis , and existential factors. (Yalom, 1995 ) 7 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Molescents — IRC- CSAC 4. List staffmg needed for your program, including required experience and estimated hours per week in program for each staff member and/or volunteers (this section should conform with the information in the Position Listing on the Budget Narrative Worksheet). Two therapists requiring 3 hours per week per group . There will be 10 weekly outpatient groups requiring a total of 15 hours per week per therapist, a total of 60 hours per week. This includes group preparation, advertising activities, screening for appropriateness of potential group members, contacting parents of referred clients to solidify group member participation, outreach to promote the group, and facilitating the weekly one hour Group Therapy Program . After each group, progress notes will be maintained as well as outcome data. 5. How will the target population be made aware of the program? Target population for the Group Therapy Program will be made aware of the group by referrals from the Center for Emotional and Behavioral Health in-patient and outpatient therapists and physicians . Flyers will be distributed in the community via the Vero Beach Community Health Fair, distribution to Indian River County Schools via Student Support Specialists. The group will be advertised in the Indian River Memorial Hospital calendar, published in the Vero Beach Press Journal , as well as, on the web and the Hospital Newsletter, 6. How will the program be accessible to target population (Le ., location, transportation, hours of operation) ? The Group Therapy Programs will be located at CEBH across the street from IRMH and easily accessible from US 1 or Indian River Blvd . The hours of operation will be after school approximately, 3 : 00p .m . to 5 : 00p .m. Monday through Friday. These Group Therapy Programs will adhere to the same schedule of operation as the Indian River County School Calendar. 8 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC D . MEASURABLE OUTCOMES (Description of Intent) Use the Measurable Outcomes form. This description page does not need to be included in the proposal. In order to show the impact that your program is having on the target population and the community, the funders are requiring measurable outcomes . Please review the examples and summaries below to insure your understanding of what is expected. OUTCOMES : Describes what you want to achieve with the target population. Indicates the results of the services you provide, not the services you provide. Outcomes utilize action words such as maintain, increase, decrease, reduce, improve, raise and lower. ACTIVITIES : Describes the tasks that will be accomplished in the program to achieve the results stated in the outcomes . Activities utilize action words such as complete, establish, create, provide, operate, and develop . The activities should reflect the services described in the PROGRAM DESCRIPTION (C2) . Use the following elements to develop your outcomes. All elements must be included: • Direction of change • Timeframe • Area of change • As measured by • Target population • Baseline: The number that you will be • Degree of change measuring against Example 1 (Outcome) : To decrease (direction of change) number of unexcused absences (area of change) of enrolled boys and girls (target population) by 75 % (degree of change) in one year (timeframe) as reported by the 2003 School Board attendance records (as measured by). Baseline : 2003 School Board attendance records for enrolled boys and girls . Example 1 (Activity) : To provide anger management classes to enrolled boys and girls 2 times a week for 12 weeks . Example 2 (Outcome) , 75 % (degree of change) of youth (target population) who have participated in the academic enrichment activities (as measured by) for 6 months or more (time frame), will improve (direction of change) their scores in one or more subject area (area of change) . 25 % of participants in academic enrichment activities will maintain the initial level of performance assessed at entry. Baseline : Pre-test scores from the academic enrichment test . Example 2 (Activity) , 1 ) Provide pre and post-test exercises on the Advanced Learning System software; 2) Participants will go through the one lesson per week and be graded for 10 weeks . IMPORTANT NOTE : Keep in mind when developing your PROGRAM OUTCOMES , that if funded, this will be what you are held accountable to accomplish . Also , the PROGRAM OUTCOMES should reflect the information described in the PROGRAM NEED STATEMENT (B 1 ) . All Program Need Statements should flow from the Mission & Vision . Measurable Outcomes should be based on and measure program needs . Activities are the tasks you do that are going to influence the outcome and impact the unacceptable condition in your Program Need Statement . 9 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC D . MEASURABLE OUTCOMES (Entire Section D not to exceed two pages) OUTCOMES ACTIVITIES Add all of the elements for the Measurable Outcome(s) Add the tasks to accomplish the Outcome(s) Children ' s Group . 1 . To increase patients understanding of their 1 . Patients will complete an evaluation that feelings by 80% . asks them to rate their understanding of their 2 . To increase patients awareness of feelings , social skills, anger management appropriate social behaviors by 80% skills, loss , and self-esteem 3 . To increase patients awareness of appropriate expressions of anger by 80% 4 . To increase patients level of self-esteem by 80% . 5 . To provide a safe place for children to talk about loss and reduce the level of anxiety losses can cause in their lives by 80% Baseline : Patient evaluation and parent evaluation Adolescent Groups . A. Anger Group 1 . To decrease the level of anger the client 1 . Patient will complete an evaluation that asks feels by 80% of premorbid level . them to rate the level of anger they feel ; rate 2 . To increase the use of anger management the frequency with which they use new anger skills to 80% frequency rate. management skills ; rate the frequency of 3 . To increase the appropriate expression of appropriate expression of anger. anger to 80% frequency rate. Baseline: Patient evaluation and parent evaluation B . Self-Mutilator Group : 1 . To decrease the level of anxiety by 80% 1 . Patient will complete an evaluation that that causes the client to self-mutilate. asks them to rate the level of anxiety they feel ; 2 . To increase the use of coping skills rate the frequency in which they use new replacing the self-mutilation behavior to an coping skills to express anxiety as opposed to 80% frequency rate . utilizing maladaptive behaviors of self- 3 . To increase the appropriate expression of mutilation. anxiety by 80% . Baseline : Patient evaluation and parent evaluation C . Sexual Abuse/Trauma Group : 1 . Patient will complete an evaluation that asks 1 . To decrease the level of traumatic them to rate the level of traumatic symptoms symptoms that are interfering in the that are interfering with the patient ' s life. To patient ' s quality of life by 80% . rate the frequency rate of using appropriate coping skills that help manage traumatic 10 C s s The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC OUTCOMES ACTIVITIES Add all of the elements for your Measurable Outcome(s) Add the tasks to accomplish the Outcome(s) 2 . To increase the use of appropriate coping symptoms . To rate the effectiveness of the skills that help manage traumatic therapists at providing a safe place to process symptoms by an 80% frequency rate. the traumatic experience. 3 . To provide a safe place to process the traumatic experience. Baseline : Patient evaluation and parent evaluation D . Family Issues Group 1 . To decrease the level of symptoms related 1 . Patient will complete an evaluation that asks to family problems that are interfering in them to rate the level of symptoms related to the patient ' s quality of life by 80% . family problems that are interfering in their 2 . To increase the use of appropriate coping quality of life. To rate the increase of skills that help manage family problems appropriate coping skills that help manage and symptoms related to these problems by family problems and symptoms related to these an 80% frequency rate. problems . To rate the effectiveness of the 3 . To provide a safe place to process the therapists at providing a safe place to process patients feelings about their family. the patients feelings about their family. Baseline: Patient evaluation and parent evaluation E . Drug and Alcohol Group 1 . To decrease the use of drugs and alcohol 1 . Patient will complete a pre and post between 80%- 100% . evaluation that asks them to rate the level of 2 . To increase the patients awareness of the drugs and alcohol use they are engaged in. To negative effects drugs and alcohol has on rate their awareness of the negative effects functioning. drugs and alcohol and their level of awareness 3 . To increase the patients awareness of the of the positive effects of abstinence. To also positive effects of abstinence . rate their awareness of high-risk relapse 4 . To increase the patients awareness of high situations and their level of understanding risk relapse situations about alternative positive activities to engage 5 . To provide alternative positive activities to besides drug and alcohol use. engage besides drug and alcohol use. Baseline: Pre and post evaluation. 11 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Ajlolescents — IRC- CSAC E . COLLABORATION (Entire Section E not to exceed one page) 1 . List your program' s collaborative partners and the resources thata they are providing to the program beyond referrals and support. (See individual funder requirements for inclusion of collaborative agreement letters .) Collaborative Agency Resources provided to the ro ram Indian River Memorial Hospital and Provides physical plant for the Group Therapy Programs Center for Emotional and Behavioral and consultation with psychiatric and psychological Health team members . Florida Institute of Technology Doctoral Practicum students assist with development of pre and post patient evaluation forms, development of structure and boundaries of group process, and research of disorders and treatment modalities Department of Children and Families Provide consultation and follow-through for continuum of care. Children ' s Home Society Provide consultation and follow-through for continuum of care Indian River County School District Provide consultation and follow-through for continuum of care Various Pharmacological Companies Provide information and educational pamphlets regarding psychotropic medications 12 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC F. PROGRAM EVALUATION (Entire Section F not to exceed two pages) 1 . DEMOGRAPHICS : What information (data elements) will you need to collect in order to accurately describe your target population including demographics (age, gender, and ethnic background) required by the funder in Section H ? What are the pieces of information that qualify them foryour target population ? How do you document their need for services or their " unacceptable condition requiring change" from Section Bl ? We will track the following demographics as provided by the parents via the registration form : ❖ Age ❖ Gender ❖ Ethnic Background •'• Family income •'• School attending •'• Medications ❖ Zip code Center for Emotional and Behavioral Health outpatient therapists ' will collaborate with community mental agencies and Student Support Specialist to identify potential children and adolescents who have been unable to make improvements in their maladaptive behaviors in individual therapy or from other support services (i . e. patient continues to self mutilate) 2 . MEASURES : What data elements will you need to collect to show that you have achieved (or made progress toward) your Measurable Outcomes in Section D ? What tools or items are you using as measures (grades , survey scores, attendance, absences, skill levels) for your program? Are you getting baseline information from a source on your Collaboration List in Section E ? Are there results from your Activities in Section D that need to be documented ? How often do you need to collect or follow-up on this data ? Pt will perform a self assessment and will complete an evaluation form that will measure outcomes that they have achieved or made progress towards mental wellness goals . A pre and post test will be utilized to measure progress in drug and alcohol group . Pt. evaluation form : Self assessment Pre and post test for drug and alcohol group Parent report : feedback sheet 3 . REPORTING : What will you do with this information to show that change has occurred ? How will you use or present these results to the consumer, the funder, the program, and the community? How will you use this information to improve your program? The pre and post evaluations will be entered into a database and the outcomes will be charted and measured . We will keep all returned self-assessment sheets for one year, to reference as needed . Quarterly Reports will be submitted to the funding agency and reports will be supplied to the local professional and school parties . Adjustments will be made based on study findings . 13 The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC G. TIMETABLE (Section G not to exceed one page) 1 . List the major action steps , activities, or cycles of events that will occur within the program year. New programs should include any start-up planning that may occur outside the funding year. In completing the timetable, review information detailed in prior sections . Month/Period Activities June 2004 Begin advertising and contacting referral sources . Create a list of potential group members orienting them to the group process . July 2004 Develop registration form that includes all demographics . Compile research and develop curriculum of each group therapy program . Develop pre and post evaluations . Screen potential group members have them complete intake form August 2004 Contact groups members inform them of the first meeting September 2004 Begin first group session . Take attendance, complete pre-test and begin the group process December 2004 Children ' s group will follow same format as adolescent group except their cycle will be five weeks with four cycles per semester ( 18 weeks) Adolescent Groups will end. Groups members will complete post-test evaluation form Develop the second 18 week group curriculum tailoring it to the needs of the identified group population, Compile goals of group members and determine outcomes January 2005 - Give parents demographic form to complete and patients pretest June 2005 evaluation form, compile goals and chart data Second 18 week groups begin, initial group curriculum based on the group member ' s need identified by intake/registration form . Compile post test data evaluation information, compile outcomes for each group Wrap up group data for grant information (employee paycheck, June 2005 cancelled checks , finance department. 14 It lot b 5CD CD a H o o 00 .p r tr b p. < O a CD PDD o O y CD d p ELEL �G Z RL < ::. t . ,zJ � s " ' Z C> 3 �� ". O � � �•�, � x yy i u ; ';;i' i 'h •` l O Omni ommew owe owe Met 0+ Fr m y pN n• ri Gr C �_ c • s '� The Center for Emotional and Behavioral Health @IRMH— Group Therapy Program for Children and Adolescents — IRC- CSAC I. BUDGET FORMS - To open the Budget Forms, please double-click on the icon below. 16 CE8H@1RMH/ Group Therapy for Children and Adolescents UNIFORM GRANT APPLICATION BUDGET NARRATIVE WORKSHEET IMPORTANT: The Budget Narrative should provide details to justify the amount requested in each line item of the budget for your program. From this worksheet, your figures will be linked to the Total Agency Budget, Total Program Budget and Funder Specific Budget Forms. AGENCY/PROGRAM NAME : CEBH@IRMH/ Group Therapy for Children and Adolescents FUNDER : IRC-CSAC CAUTION : Do not enter any rigures where a cell is colored in dark blue - Formulas and/or links are in place. Gray areas should @be used for calculations and to write information oni , : . . •._.: ::i ts.:. ::.::::::.:<?f .::. ::::: . . .::._ . ::::::. : . . . . . . . . .. . . . ... . ... . .: :.:::.::�:::::::.�::::::::::;#� €Jit: '�:::::::::::::;::.;:.:;.:.;•.:;:::: ::::. .:: . .::::::::.:::::::::.::.>:;:. . . . . .. . . . :::.�:.�::::::.�.�:: <..v�' . . . . .. . . ::t3 . . . . . . . . . . .. . .. . . . . . . . .. . . . . . . . . . . . . . . . . 1 Children's Services Council-St Lucie 2 Children's Services Council-Martin 3 Advisory Committee4ndian River 51 ,005.07 51 005.07 1523605.07 4 United Way-St. Lucie County 5 United Way-Martin County 6 United Way-Indian River County 7 Department of Children & Families 8 County Funds 9 Contributions-Cash 10 Program Fees 91000.00 68700,000.00 11 Fund Raising Events-Net 12 Sales to Public - Net 13 Membership Dues 14 Investment Income 15 Miscellaneous 16 Legacies 8, Bequests 2v000.00 17 Funds from Other Sources 18 Reserve Funds Used for Operating 19 In-Kind Donations- IRMH 28,544038 20 TOTAL REVENUES (doesnl include line 19 :? :#:> :s::::: 'i: i ?<>:: 's:': $60,005.07 $511005.07 $6,854,605.07 D .:::::::. . ::::•:. : ' iSR �6rts:•';-:::; : # : : :;:: ::: ::::: :: ::: ::y: ti: ::is ','';%i:::;:::::: :: $:i:: : ? : : : :> i > � :.: ::: ::::.::::::::::.:::::::::::::::. ::: :.:ter >: ,. :::::::::.: .::::::::::::::. ::: ` ! .wx :. ::::::::::::. . :::.::::::::::: . . :.: :.: . . . . . . . . . . . . . . . :. ::::::.. .::.: .::. :.: . :. :::: :. .: :::. . :. . . . . .: . .:. :::::::. :::::. :::._ Wig 21 Salaries - (must complete chart on next page) 47 380.46 47 380.46 335511447.21 22 FICA - Total salaries x 0.0765 3,624.61 31624 .61 2719685.71 Retirement - Annual pension or qua i ie 23 staff > < ABlo 2,279.00 0 .00 170,824 .61 Life/Health - ica en a o - erm 24 Disab. 7 ,699.32 0 .00 577, 110. 17 Workers Compensation - # employees x 25 rate s ". 7 . '' 838.63 0.00 62 ,860.62 Florida unemployment - projected 26 employees x $7,000 x UCT-6 rate (E;9$aCo 227.43 0 .00 17 ,046 .95 05242004 B-1 s � � CEBH@IRMH/ GFoupTherapyforCNdrenand Adolescents e /O. S : .^.. : :: ::ii;'::::f: : % ; : . : : ::; <:: i: :2:::;:ik:: :: . ::::: .:::: :: % : : ;.:: 9 .'; :.::.>::;':;: '.•';:>: ::::::i: . . :. �tlrT(ICI: .�:.alu.�Y(Gf655 . . . . :. . ::. . :::::::::::::::::: . . . . . . . . . . . . . . . . . . . . . . . . . .�!. .rlf4ltt:o€.�,+�t.� : .;!bft.:i�!� atl»::> : ;;>:<>:;.>:::;;:; >::>:�::»:� >:: :>:: >:.;;;:;:::�: .. .:.. »::r ::::: . :. .: . . .: . . .. . . . .. . . . . .. . . . . . . . . .. . . . :::::. :::. :. :::::: . . . . . . . . . . . . . . . :. :::::::.:::.: ::: . . . . . . .. . . . . . . . . :. :. :::::: . . . . . . . . . . :: .::: . . . .:::. . ;,,,. Agen ef� ;::.; ;:: .;:.;:.;:.;:;.;:.;;; •;:;:.;:<.;:.;;;:.; <:.<;:.;;:.;;::.:.;;:;.;: :;.;;: >;".;:.:;::: :.;;.:: ;;:.;;:.;:;.:;:.;:.::.:;.:;.;:<;: .:;.;:.;:.;;:.; .;:::;;;;:.;:.>;: :.;:.;;;;;:.;:.;:.;:.;;;;;;:.:.;:.;>.:.;;;:.;;;:.;:.;:.;:.;:.;:.;;. . . . . . . It . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . ::. :. ::::.: ::::::::. . .: .. : . . . . . . . . . . . . . . . . . . :. . . . :. . :::.:::::::.::::::::::::::.:: .::::, . . . . . . . . . . . . .. . . ::.:�:::.::: ..�:: . . . . . . . . . . . . . . . . . . . . . . :::::::::: . . .. . . . . . . . . . . . .. . . ::x!_::: . . . . . . . . [. . .+41. . .. . : te. : keerrYi9 8llirectul . . . . . . . hs:::::: " ::•::::: ::::::: . . . . . !`O,t1009� :.;::::;:,:::••";:";;::";:";:";:::<.:;:�;: ;:";;. ;: :•;::;�•.>l E#DfV/O! 'fPsychology Fellow/80 hrs 85,696.00 22 ,280.96 22 ,280.96009'Therapist/80 hrs 96,536.54 25099.50 25,099.5000°/ #DIV/0! #DIV/0 ! #DN/0! #DN/0! _ #DN/0! #DIV/0! #DN/0! #DIV/0! #DIV/0! #DN/0! #DN/0! #DIV/0! #DIV/0! #DIV/0! #DN/0! Remaining positions throughout the agency 31369,214.67 Total Salaries $30551 ,447.21 $47,380.46 7 380.46 1 .339 ': ' ::`;::: 2 � � < ' '•.':ii � f ? � y �: % 2 ' . : I. . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . .. . ...... ...:i :" :is ::: : �::i: .: ::::i: .::: ;� :: ::>:: : :: ::: : : f: :. :: ::?:: :r``.:: . . . . ... ::: ' ::: :....: :••< >�<;;<::>::;; <:••:; ::: ::.:�:::;:::;>:: ::>;•: : ::;:>:;;;;:•:»•::::<;:.>;»::•:>:::«:i:::;:: >::::::>:.:. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . .4Swr7cev�s.:.�:. x7rran .: . :, :.:. ::. ;. .; .;::. ::::.�.�:.� /��� }},,ma�y�,.. �yy j.,.,,._:: . .::::.�:::. :::::.: . . :.:: . .::.� :.:::.:; .7. �.. .:::: :.. . . .:::. :�.i►►.s.. . . . :. . . .: . :. .:�.�.�::..� :..� .: . . .::::::::.�:::.:: .:::. ;. ;:. .. . :. . ::�.:::::::::.::::•::: XX 1.R1ltJ; : . `::�I��:�1R�FF:::Xi/i:�:fi!: _ �:::;;::;:::::: :::>:::�: .:;:::i:::: ::.:::.:..::.: .::•:::::•. .:.� :. .9 ::: ::::::::.�::::::: .�.: :::: :.:.� .. . . . . . .. .: ::::.:::::: . . . . . . : .:::::::.::.�. . �`ofal:#ltsl . . . . . . . .N. . . . . . . . f+i :lis.::::. :::::::::::::::::::::::. :;>;;:.; .;•;:. . dIQl1� :.:::.::: &2s <:::>::>::>::2D11iDD. .:_:: . . . .. . . . . . . . . . . . . . .. .. . . . .. . . . . . . .. . . . . . . . . . . . . . . : ::::::. : ►n tom. :::. ::::. :: : :>::»> > ::idd 9�► :: <::::<:::>::> >:::>:< :»: ;;::: ;581;5{ Psychology Fellow/80 hrs 22,280.96 1 ,704.49 0.00 0.00 0.00 0.00 1 ,704.4 Therapist/80 hrs 25,099.50 13920.11 0.00 0.00 0.00 0.00 1 ,920 0, p, .11 0 0.00 0.00 0 0.00 0.00 0 0.0010.00 0.0 0 0.00 0.00 0. 0 0.00 0•p0 0. 0 0.00 0.00 0, 0 0.00 0.00 p, 0 0.00 0.00 0. 0 0.00 0.00 0• 0 0.001 0.00 0.0 0 0.001 0.00 0, 0 0.00 0.00 0.0 0 0.00 0.00 0• 0 0.00 0.00 0.0 0 0.00 0.00 0 0 0.00 0.00 1 0.04 0 0.00 0.00 0.0 0 0.001 0.00 0.0 Total Funder Request Fringe Benefits I $41t:380.461 $3524.61 $U,Uul $0.001 $0.00 $0.00 $3,624.61 05242004 B-1 CEBH@IRMHf Group Therapy for Children and Adolescents a xx :: : z.... _`:' .: _: :_'i.": ::>::: : •- :: :: •::• • ; ;- .'-r.: .i:: SG:`: : :::i:: : i :i :::: : :::::.`;:i::>�`::: ':::'::: .i':>;::i::::::: .:-::: -;? . . . . . . . . . . :. .. .: . . . . . . :: : ::.>::;.;i:: >i:: :5: ;: i :: : :; : : : i;:::-: > ::;: >:: <:«:> :>:>:<:::; :>:: <:>;:<:::»::>;� <:::::>::>::>::>::>::»»;::» ;«::<: <:>:>:»>:> ::: . . . . . . . . . . . . . .. . . ..h� a : : 27 Travel -Daily 0.00 0.00 2,635.77 ave a e of ' of Staff x r # mhles/wk 50 # x wks x :: 9 EtRlbe s .mat d DailyTravel/Mile a e' a9 m . '.w 28 Travel/Conferences/In-HouseTraining 0.00 0.00 50,035.64 Conference co • Nationaln stPe r staff) - • Training/Seminar cost per staff) ( P s (costI I • Other 1'rairn9 n of travel, lodging,h n 9, registration, food)) 2ft PP 9 Office Supplies s 200.00 0.00 48,249.00 • Office supplies (monthly average x12 = es ima o months t ted cost of office s uPP lies . . . . . . . . . . . . . .. . . . . .. . . . . . : ` : c .. : ` " _: :: ' > : : .. ' > :== > : < <: :> : : .. : ::: : : ::: : >: ..... ::;:::<:> :::: ::»:.:based on present history. : :: >: ' : : : :: : ::: :::. ...:: ' > >':: ::: : > : :: ': : :: : . . . : : : > . ; <:. .. . 30 Telephone 200.00 0.00 44,805.00 • > ..# Phone lines x average cost per month x 12 < :< :z >:< . .. <:::: :> ::>:<::<:>:»::> »:::<:::::>::>: z:>:^::>:: ::<:» : : : : >::::»> months = local phone cost • elo distance = Avera n d t nce calls x12mo months 9 9 Estimated cost of long distance 31 Postage/ hipping ••••••••••••••••••••••••••••••••••••• ••• • ••• • •••• 100.00 0.00 1 ,638 .00 • uarte Mallen of Newsletter wsletter �Y . 9 Special• events,ventse tc. • ail. s a Bulk m n9 - appeals 32 Utilities 1 ,250.00 0.00 66,636.00 c o } • Elect. x Z months)nths • . . . . . . . . . . . . . . . . to /Sewer Wa r x 12 months • Garb9 Garbage ($ x 12 m 0 s) 33 Occupancy (Building & Grounds) 12,500.00 0.00 1 ,121 ,909. 12 • ( Mortgage/Rent th x 12 mon s • I x1 0 Janet no "a 2 m nths • Grounds Maint. x 12 months) • Real Estate Taxes 34 Printing & Publications '"i ,.,.. .i'"'ii <::::::••::•••••-.:. :::::•:: CEBH@IRMH/ Group Therapy for Children and Adolescents 6 41 Books/Educational Materials . .. . . . . . ::: ;:z: ;<zz:;>:«z;«::«:>:: 5,000.00 0.00 28,657.00 s/ Bookideos v a Maten 1s x staff) 42 Food 8 Nutrition n . . . . . . . . . . . . . . . . 1.12,720.00 • Meats # meals x clients x5d a sx50 wks <` • Snacks 43 Administrative tv Costs 5,000.00 0.00 567,617.55 Cost � of total b • Admin . ud et 9 44 Audit Expense e :•::•::::.�:::::•::::::::: 0.00 independent Audit Review 45 Specificecific Assistance to Individuals 0.00 • Medical assistance • Meals/Food Rent Assistance • Other _ 46 Other/Miscellaneous 0.00 11575.00 Background cher d • Back k/ ru test • 9 9 Other 47 Other/Contract 0.00 7401000.00 r • Sub-contract for program services P rnces 481 TOTAL EXPENSES $88,549.45 $51 ,005.07 $8,138,301 .59 05/24/2004 B-1 !ENiq, F (Zr 0nWMV fn CNhY BM AikMb�MtS UNIFORM GRANT APPLICATION TOTAL AGENCY BUDGET AGENCY/PROGRAM NAM E :CEBH IRMH/ Group Therapy for Children and Adolescents FY 02/03 FY 03104 FY 04105 % INCREASE FYE 9/30/2003 FYE_9I3012004 FYE 9/30/2005_ CURRENT VS. NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED Icol Cool. BNcol. B REVENUES BUDGETED BUDGETED 1 Children's Services Council-St Lucie 0.00 #DIV/O! 2 Children's Services Council-Martin 0.00 #DIV/0! 3 Advisory Committee-Indian River 20 000.00 24,445.00 152 605.07 524.28% 4 United Way-St Lucie County 0.00 #DIV/0! 5 United Way-Martin County 0.00 #DIV/0! 6 United Way-Indian River County 0.00 #DIV/0! 7 Department of Children & Families 0.00 #DIV/0! e County Funds 0.00 #DIV/0! - 9 Contributions !Cash 0.00 #DIV/0! 10 Program Fees 69931j136.00 6900000.00 6,7009000.00 -2.90% 11 Fund Raising Events-Net 0.00 #DIV/0! 12 Sales to Public-Net 0.00 #DN/01 13 Membership Dues 0.00 #DIV/01 14 Investment Income 0.00 #DN/0! 15 Miscellaneous 0.00 #DN/0! 16 Legacies & Bequests 27000.00 #DMO! 17 Funds from Other Sources 0.00 #DIV/01 1e Reserve Funds Used for Operating 0.00 #DIV/01 19 In-Kind Donations Mot kwkj&d In totaq 0.00 #DIV/0! 20 TOTAL 619510136.00 6,924 445.00 61854,605.07 -1 .01 % EXPENDITURES 21 Salaries 3,446 298.00 31448v007,00 3t5619447,21 3.00% 22 FICA 240 456.00 263 902.00 271 685.71 2.95% 23 Retirement 165 766.93 165 849.14 170 824.61 3.00% 24 LifelHealth 560y023,43 560 301 .14 577 110.17 3.00% 25 Workers Compensation 60 999.47 61 029.72 627860.62 3.00% 26 Florida Unemployment 1654223 16 550.43 17#046,95 3.00% 27 Travel-Daily 2 389.00 21559.00 21635.77 3.00% 2e Travel/Conferences/Trainin 49 549.00 4954900 50 035.64 0.98% 29 Office Supplies 47 051 .00 48 249.00 48 249.00 0.00% 3o Telephone 42157.02 43,460.85 44,805.00 3.09% 31 Posta e/Shi in 1 547.00 1 ,638.00 1j638.00 0.00% 32 Utilities 66182.00 61 700.00 66 636.00 8.00% 33 Occupancy (Building & Grounds 1 ,135,899.00 111199712.00 1 121 909.12 0.20% 34 Printing & Publications 3145.00 $1331 .00 31464.24 4.00% 35 Subscription/Dues/Memberships 1 ,705.00 11524.00 1 ,524.00 0.00% 36 Insurance 390,200.00 355 200.00 360 000.00 1 .35% 37 E ui ment:Rental & Maintenance 8,514.00 91650.00 91650.00 0.00% 3e Advertising 41996.00 51000.00 51000.00 0.00% 39 Equipment Purchases:Ca ital Expense 13115.00 179557.00 17,557.00 0.00% 40 Professional Fees (Legal, Consulting) 303 850.00 303,850.00 303,653.00 -0.06% 41 Books/Educational Materials 249349.00 289657.00 28,657.00 0.00% 42 Food & Nutrition 117,636.00 110 880.00 112,720.00 1 .66% 43 Administrative Costs 551 ,085.00 559 ,351 .28 567 617.55 1 .48% 44 Audit Expense 0.00 0.00 0.00 #DIV/01 45 Specific Assistance to Individuals 0.00 0.00 0.00 #DIV10! 46 Other Miscellaneous 800.00 800.00 11575.00 96.88% 47 Other/Contract 739,421 .00 7407000.00 740,000.00 0.00% 48 TOTAL 07$993,676.09 77978,307.56 89138 ,301 .59 2.01 % 49 REVENUES OVER1 UNDER EXPENDITURES -1 ,042,540.09 -1 ,053,862.56 .1 ,283 ,696.52 21 .81 % n4:aRxx B-2 . < s �ESFWIX AtY i� Thx^ Irc (NWerM M!45 ,. MS a UNIFORM GRANT APPLICATION TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME :CEBH IRMH/ Group Therapy for Children and Adolescents FY 02/03 FY 03104 FY 04105 % INCREASE FYE_913012003 FYE 9/30/2004 FYE_9/30/2005 CURRENT VS, NEXT FY BUDGET A B C D ACTUAL TOTAL PROPOSED (col. C.cul. BUccl. s REVENUES BUDGETED BUDGETED 1 Children's Services Council-St. Lucie 0.00 #DIV/0! 2 Children's Services Council-Martin 0.00 #DIV10! 3 Advisory Committee-Indian River =0.00 07 #DIV10! 4 United Way-St Lucie County00 #DIV10! 5 United Way-Martin County00 #DIV10! 6 United Way-Indian River County00 #DIV10! 7 Department of Children & Families 00 #DIV/O! s CountyFunds _ #DN10! 9 Contributions-Cash 0.00 #DIV10! to Program Fees 91000.00 #DIV101 11 Fund Raising Events-Net 0.00 #DIV/01 12 Sales to Public-Net 0.00 #DIV/0! 13 Membership Dues 0.00 #DIV10! 14 Investment Income 0.00 #DIV10! 15 Miscellaneous 0.00 #DIV10! 16 Legacies & Bequests 0.00 #DIV/O! 17 Funds from Other Sources 0.00 #DIV10! 1s Reserve Funds Used for Operating 0.00 #DIV/01 19 In-Kind Donations Mot encN,d.d in maQ 28 544.38 #DIV10! 20 TOTAL 0.00 0.00 60,005.07 #DIV10! EXPENDITURES 21 Salaries 47,380.46 #DIV10! 22 FICA 31624.611 #DN/0! 23 Retirement 2y279.00 #DIV10! 24 Life/Flealth 71699.32 #DIV10! 25 Workers Compensation 838.63 #DIV/0± 26 Florida Unemployment 227.43 #DIV10! 27 Travel-Dail 0.00 #DIV10! 26 Travel/Conferences/Training 0.00 #DIV10! 29 Office Supplies 200.00 #DIV10! 30 Telephone 200.00 #DIV/O! 31 Postage/Shipping 100.00 #DIV/01 32 Utilities 11250,001 #DIV/01 33 Occupancy (Building & Grounds 12,500.00 #DIV/O! 34 Printing & Publications 100.00 #DIV/01 35 Subscription/Dues/Memberships 150.00 #DIV10! 36 Insurance 21000.00 #DIV/01 37 E ui ment:Rental & Maintenance 0.00 #DIV/01 3s Advertising 0.00 #DIV/01 39 Equipment Purchases :Ca ital Expense 0.00 #DIV101 40 Professional Fees (Legal, Consulting) 0.00 #DIV/0! 41 Books/Educational Materials 57000.00 #DIV/0! 42 Food & Nutrition 0.00 #DIV10! 43 Administrative Costs 51000.00 #DIV/01 44 Audit Expense 0.00 #DIV/0! 45 S eci&; Assistance to Individuals 0.00 #DIV/0! 46 Other/Miscellaneous 0.00 #DIV10! 47 Other/Contract 0.00 #DIV10! 48 TOTAL 0.00 0.00 88,549.45 #DIV/0! 4s REVENUES OVER/ UNDER EXPENDITURES 0.001 0 .00 -281544.38 #DIV/01 itV +1Pxb 9J CEBH@IRMH/ Group Therapy for Children and Adolescents UNIFORM GRANT APPLICATION FUNDER SPECIFIC BUDGET PROGRAM EXPENSES AGENCY/PROGRAM NAME : CEBH@IRMH/ Group Therapy for Children and Adolescents FUNDER : IRC - CSAC A B C FY 04/05 FY 04/05 % OF TOTAL FUNDER TOTAL VS. PROGRAM SPECIFIC FUNDER REQUEST BUDGET BUDGET (col. B/col. A) EXPENDITURES 21 Salaries 471380.46 47,380.46 100.00% 22 FICA 3 ,624.61 31624.61 100.00% 23 Retirement 27279.00 0200 0.00% 24 Life/Health 71699.32 0 .00 0.00% 25 Workers Compensation 838.63 0 .00 0.00% 26 Florida Unemployment 227.43 0.00 0 .00% 27 Travel-Daily 0.00 0.00 #DN/01 28 Travel/Conferences/Training 0.00 0.00 #DIV/01 29 Office Supplies 200.00 0 .00 0 .00% 3o Telephone 200.00 0.00 0,00% 31 Postage/Shipping 100.00 0.00 0 .00% 32 Utilities 1 ,25000 0.00 0.00% 33 Occupancy Building & Grounds 127500 .00 0.00 0 .00% 34 Printing & Publications 100.00 0.00 0.00% 35 Subscription/Dues/Memberships 150.00 0 .00 0.00% 36 Insurance 21000.00 0.00 0.00% 37 Equipment: Rental & Maintenance 0.00 0 .00 #DIWOI 38 Advertising 0 ,00 0,00 #DIV/0 ! 39 Equipment Purchases : Capital Expense 0.00 0.00 #DN/0 ! 40 Professional Fees Legal , Consulting 0.00 0 .00 #DIV/0! 41 Books/Educational Materials 59000.00 0 .00 0,00% 42 Food & Nutrition 0 ,00 0.00 #DIV/0 ! 43 Administrative Costs 51000.00 0 .00 0 . 00% 44 Audit Expense 0.00 0 ,00 #DN/0 ! 45 Specific Assistance to Individuals 0 .00 0 ,00 #DIV/01 46 Other/Miscellaneous 0 ,00 0,00 #DIV/0 ! 47 Other/Contract 0 .00 0 ,00 #DIV/0 ! 48 TOTAL $ 88 , 549 .45 $ 517005 .07 57. 60% 0524/2004 B-0 CEBHCbWWWGr0W Therapy for ChOdren and Adaftmnls 0 UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 15% OR MORE TOTAL PROGRAM BUDGET AGENCY/PROGRAM NAME: CE13H@IRMH1 Group Therapy for Children and Adolescents FUNDER: IRC - CSAC F#DIV/O! :.:: .. ... . . . . lY�. .. ::: ::: •:::. . . . ..: . 'YIiFt7 .... :i%:.. . . . . . .. . . .. . . .. .. . . . . . ., . . .: .:. #DIVIO! #DIVIO! #DIVIO! _ #DIVIO! #DIV/O! #DIV/O! #DIVIO! #DIV/O! #DIVIO! #DIVIO! #DIV/O! #DIVIO! #DNIO! #DIV/O! #DIV/O! #DIV/O! #DIVIO! #DIV/O! #DIV/O! #DIV/O! #DIV/O! #DIVIO! #DIV/O! #DIV/O! #DNIO! #DIVIO! #DIV/O! #DIV/O! #DIV/O! #DIVIO! #DIVIO! #DIVIO! #DIV/O! #DIVIO! #DIVfO! #DIV/O! #DIV/O! #DIVIO! #DIVIO! #DIV/O! 0524M04 B-s F r CEM4@M" Cr*W Thm" fm Ct*&en end Ado* ends UNIFORM GRANT APPLICATION EXPLANATION FOR VARIANCES OF 16% OR MORE FUNDER SPECIFIC BUDGET AGENCYIPROGRAM NAME: CEBH@IRMH/ Group Therapy for Children and Adolescents FUNDER: IRC - CSAC Salaries Requestin 100% of staff salaries FICA Requesting 100% of FICA for staff salaries #DIVIO! #DN/0! #DIV/01 #DN/O! #DIV/0! #DIV/O! #DIV/O! #DN/0! #DIV/0! #DIV/01 #DIVIO! osaen°oa e-s EXHIBIT B [From policy adopted by Indian River County Board Of County Commissioners on February 19 , 2002] " D . Nonprofit Agency Responsibilities After Award of Funding Indian River County provides funding to all nonprofit agencies on a reimbursement basis only. All reimbursable expenses must be documented by an invoice and/or a copy of the canceled check . Any expense not documented properly to the satisfaction of the Office of Management & Budget and/or the County Administrator may not be reimbursed . If an agency repeatedly fails to provide adequate documentation , this may be reported to the Board of Commissioners . In the event an agency provides inadequate documentation on a consistent basis , funding may be discontinued immediately. Additionally, this may adversely affect future funding requests . Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For example , no expenditures prior to October 1St may be reimbursed with funds from the following year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not carried over to the next year unless expressly authorized by the Board of Commissioners . All requests for reimbursement at fiscal year end (September 30th) must be submitted on a timely basis . Each year, the Office of Management & Budget will send a letter to all nonprofit agencies advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early to mid October, since the Finance Department does not process checks for the prior fiscal year beyond that point . Each reimbursement request must include a summary of expenses by type . These summaries should be broken down into salaries , benefits , supplies , contractual services , etc. If Indian River County is reimbursing an agency for only a portion of an expense (e . g . salary of an employee ) , then the method for this portion should be disclosed on the summary. The Office of Management & Budget has summary forms available . Indian River County will not reimburse certain types of expenditures . These expenditure types are listed below. a . Travel expenses for travel outside the County including but not limited to ; mileage reimbursement, hotel rooms , meals , meal allowances , per Diem , and tolls . Mileage reimbursement for local travel (within Indian River County) is allowable . b . Sick or Vacation payments for employees . Since agencies may have various sick and vacation pay policies , these must be provided from other sources . c . Any expenses not associated with the provision of the program for which the County has awarded funding . d . Any expense not outlined in the agency's funding application . The County reserves the right to decline reimbursement for any expense as deemed necessary." - 1 - + c EXHIBIT C STANDARD TERMS FOR GRANT CONTRACT 1 , Notices : Any notice , request , demand , consent, approval or other communication required or permitted by this Contract shall be given or made in writing , by any of the following methods : facsimile transmission ; hand delivery to the other party; delivery by commercial overnight courier service ; or mailed by registered or certified mail (postage prepaid ) , return receipt requested at the addresses of the parties shown below: County: Joyce Johnston -Carlson , Director Indian River County Human Services 184025 th Street Vero Beach , Florida 32960-3365 Recipient : Mariamma Pyngolil , RN , Program Director Center for Emotional & Behavioral Health 119037 1h Street Vero Beach , Florida 32960 2 . Venue ; Choice of Law: The validity, interpretation , construction , and effect of this Contract shall be in accordance with and governed by the laws of the State of Florida , only. The location for settlement of any and all claims , controversies , or disputes , arising out of or relating to any part of this Contract , or any breach hereof, as well as any litigation between the parties , shall be Indian River County, Florida for claims brought in state court, and the Southern District of Florida for those claims justifiable in federal court. 3 . Entirety of Agreement :. This Contract incorporates and includes all prior and contemporaneous negotiations , correspondence , conversations , agreements , and understandings applicable to the matters contained herein and the parties agree that there are no commitments , agreements , or understandings concerning the subject matter of this Contract that are not contained herein. Accordingly, it is agreed that no deviation from the terms hereof shall be predicated upon any prior representations or agreements , whether oral or written . It is further agreed that no modification , amendment or alteration in the terms and conditions contained herein shall be effective unless contained in a written document signed by both parties . 4 . Severability: In the event any provision of this Contract is determined to be unenforceable or invalid , such unenforceability or invalidity shall not affect the remaining provisions of this Contract, and every other term and provision of this Contract shall be deemed valid and enforceable to the extent permitted by law. To that extent, this Contract is deemed severable . 5 . Captions and Interpretations : Captions in this Contract are included for convenience only and are not to be considered in any construction or interpretation of this Contract or any of its provisions . Unless the context indicates otherwise , words importing the singular number include the plural number, and vice versa . Words of any gender include the correlative words of the other genders , unless the sense indicates otherwise . 6 . Independent Contractor, The Recipient is and shall be an independent contractor for all purposes under this Contract. The Recipient is not an agent or employee of the County, and any and all persons engaged in any of the services or activities funded in whole or in part performed pursuant to this Contract shall at all times and in all places be subject to the Recipient's sole direction , supervision , and control . 7 . Assignment. This Contract may not be assigned by the Recipient without the prior written consent of the County. - 1 - ACORQ CERTIFICATE OF LIABILITY INSURANCE OP ID $ DATE (MM+DD/YYYY) INDIA - 1 11 / 04 / 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phones 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Admiral Insurance Co . Indian River Memorial Hospital INSURER 8: American Autcmabils Ins . co . Greg Morgan INSURER C: 1000 36th Street INSURER D: Vero Beach FL 32960 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, Y EFF LTR INSRE TYPE OF INSURANCE POLtCYNUMBFJ2 DATE MINDD/YY DATE MWD LIMITS GENERAL LIABILITY r EACH OCCURRENCE S $ 5000010 0 0 X X COMMERCIAL GENERAL LIABILITY CAPTIVE SIR 10 / 01 / 04 10 / 01 / 05 PREMISES (Ea roccuD- S X CLAIMS MADE OCCUR MED EXP (Arty one person) E PERSONAL d ADV INJURY $ $ 510001000 GENERAL AGGREGATE E $ 151 0 0 01 0 0 0 GENIL AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ 510000000 POLICYf"l JEG�T LOC AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT (Ea accident) E $ 210001000 ALL OWNED AUTOS E $ X SCHEDULED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 (BODILLYSINJURY B X HIRED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 BODILY INJURY B X I NON-OWNED AUTOS MZA80833367 10 / 12 / 04 10 / 12 / 05 (Per accident) E PROPERTYDAMAGEF1 E (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT E ANY AUTO OTHER THAN EA ACC E AUTO ONLY: �AGG i — EXCESSIUMBRELLA LWBILRY EACH OCCURRENCE E $ 2 010 0 010 0 0 A occuR KICLAIMSMADE CRL - FL - 10013 - 1002 - 03 10 / 12 / 04 11 / 01/ 05 AGGREGATE $ $ 20 / 0001000 Excess E DEDUCTIBLE Above SIR E RETENTION E $ 5M/ $ 15M E WORKERS COMPENSATION ANDSTATUO EMPLOYERS' LIABILITY TORYLIMITS I ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT E OFFICERIMEMBER EXCLUDED? Ns, describe under E.L. DISEASE • EA EMPLOY S SPECIAL PROVISIONS below OTHER E.L. DISEASE - POLICY LIMIT t DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate Holder is added as Additional Insured with respect to their interest in contract with the Named Insured . CERTIFICATE HOLDER CANCELLATION INDIANC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATBMS. _ Vero Beach FL 32960 AUT IZEDREPRE TA VE ACORD 25 (2001 /08) I © ACORD CORPORATION 1988 a : e ACORD,,, CERTIFICATE OF LIABILITY INSURANCE OP ID DATE (MWDD/YYYY) INDIA - 1 11 / 04 / 04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Florida Hospital Assoc Ins Svc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1675 Terrell Mill Rd . ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Marietta GA 30067 Phone : 800 - 476 - 7601 Fax : 770 - 850 - 0988 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Continental Casualty Company INSURER B: Indian River Memorial Hospital INSURER C: Greg Mor an 1000 36th Street INSURER D: Vero Beach FL 32960 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, MW 0%I LTR INQ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE MMR) DATE MM/ LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurenee f CLAIMS MADE OCCUR MED EXP (Any one person) S PERSONAL d ADV INJURY f GENERAL AGGREGATE f GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG S POLICY JEC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea ecddent) S ALL OWNED AUTOS BODILY INJURY s SCHEDULED AUTOS (Per Person) HIRED AUTOS BODILYINJURY $ NON-OWNED AUTOS (Per accldent) PROPERTY DAMAGE f UW soddenq GARAGE LIABILITY ALTO ONLY EA ACCIDENT f ANY AUTO EA ACC f OTHER THAN AUTO ONLY: AGG f EXCESS/UMBRELLA LIA8KJTY EACH OCCURRENCE f OCCUR F1 CLAIMS MADE AGGREGATE S f DEDUCTIBLE S RETENTION $ $ WORKERS COMPENSATION AND X TORY LIMITS ER A EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNW - 128588438 01 / 01 / 04 E O1 / O1/ 05 E.l, EACH ACCIDENT S $ 1 f 0001000 OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE i $ 1 0 0 0 1 0 0 0 III yes, I4L P �ROVISIONS below under SPECIAL E.L. DISEASE - POLICY LIMIT S $ 3L e 0 0 0 1 0 0 0 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Proof of coverage for above Named Insured , CERTIFICATE HOLDER CANCELLATION INDIANC+ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Indian River County IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 1840 25th Street REPRE TATLVES. Vero Beach FL 32960 AUT IZEDRfPRE TA VE ACORD 25 (2001108) © ACORD CORPORATION 1968 tl C Internal Revenue Service District Director Department of the Treasury Date: 'WR 2 6 1985 Employer identification Number. 59- 2496294 Accounting Period Ending: September 30 Form 990 Required: ® Yes 0 No Indian River Memorial Hospital , Inc . 1000 36th Street Person to Contact: Vero Beach , FL 32960 Brenda Wilcox/cdt Contact Telephone Number. (404) 221 - 4516 File Folder Number : 580062333 Dear Applicant : Based on information supplied ' and assuming your operations will be as stated in your application for recot3nitien of ' -e— from Federal income tax under 'section 501ewe have determined you are exempt ( c )) (( 3 )) -of the Internal Revenue Code . We have further determined that meaning of section 509 ( a ) of the Code * becauseu are a private foundation within the section 170 (b) ( 1 ) (A) (iii) S 509 (a) ( u , You are an organization described in If your sources of support , or your purposes , change , please let us know so we can consider the , effectcterof the chanhedonf operation Your exempt status and foundation status . Also , you should inform us of all changes in Your name or address . As of January 1 , 19849 you are liable for taxes under the Federal Insur Contributions Act ( social security taxes ) on remuneration of $ 100 or more pay to once each of your employees during a calendar imposed under the Federal Unemployment year . You are not liable for the P Yment Tax Act ( FUTA ) . I J Since you are not a private foundatiott , ' You are not subject to the excise taxes under Chapter 42 of the Code . However , you are not automatically exempt from other Federal excise taxes . If Federal taxes You have any questions about excise , employment , or other Please let us know . . Donors may deduct contributions to � Bequests , legacies , devises , transfers you as provided in section 170 of the Code , deductible for Federal estate and gift tax or gifts to you or for your use are Purposes if Provisions of sections 2055 , 21069 and 2522ofpthe sCodethey meet the applicable I The box checked in the heading of this letter shows whether you must file Form 9909 Return of Organization Exempt from Income Tax , If Yes is checked , you are required to file Form 990 only if your gross receipts each than $ 25 , 000 . If a return is required , p Year are normally more q it must be filed by the 15th day of the fifth month after the end of your annual accounting period . $ 10 a day , up to a maximum of $ 5 , 000 , when a return iThe law imposes apenalty of i is reasonable cause for the delay . s filed late , unlessthere e " e r lUu kirc 1/ uL rut4uireu Lo rile reaerai income tax returns unless you are subject to the tax on unrelated business income under section 511 of the Code . If you are subject to this tax , you must file an income tax return on Form 990- T , Exempt Organization Business Income Tax Return . In this letter , we are not determining whether any of your present or proposed activities are unrelated trade or business as defined in section 513 of the Code . You need an employer identification number even if you have no employees . If an employer identification number was not entered on your application , a number will be assigned to you and you will ' be advised of it . Please use that number on all returns you file and 'in all correspondence with the Internal Revenue Service . Because this letter could help resolve any . questions about your exempt status . and foundation status , you should keep it in your permanent records . If you have any questions , please contact the person whose name and telephone number are shown in the heading of this letter . Sincerely yours , District ector cc : Edward J : Hopkins William J . Stewart Letter 947 ( 00) ( Rev. 10-83)